<form action="<?php echo $this->getFormAction();?>" method="post" id="sidebar_contacter">
<input type="hidden" name="type" value="4">
<input type="hidden" name="page" value="feedback">

<div class="feedback">
				
		<div class="field_item">
			<label for="salutation"><?php echo $this->__("Salutation");?></label>
			<span class="required">*</span><br />
			<select name="title" style="width:174px;">
				<option value="1"><?php echo $this->__("Mr.");?></option>
				<option value="2"><?php echo $this->__("Mrs.");?></option>
				<option value="3"><?php echo $this->__("Miss");?></option>
			</select>
		</div>
		
		
		<div class="field_item">
			<label for="salutation"><?php echo $this->__("First Name");?></label>
			<span class="required">*</span><br />
			<input type="text" name="first_name" value="" class="input-text required-entry"  style="width:166px;">
		</div>
		 
		<div class="field_item">
			<label for="salutation"><?php echo $this->__("Last Name");?></label>
			<span class="required">*</span><br />		
			<input type="text" name="last_name" value="" class="input-text required-entry" style="width:166px;">
		</div>
						
		<div class="field_item">
			<label for="salutation"><?php echo $this->__("Email");?></label>
			<span class="required">*</span><br />
			<input type="text" name="email" value="" class="validate-email required-entry input-text" style="width:166px;">
		</div>		
		
		<div class="field_item">
			<label for="salutation"><?php echo $this->__("Feedback Or Comment");?></label>
			<span class="required">*</span><br />			
			<textarea name="content" rows="12" cols="50" class="enquiry_text required-entry" style="width: 166px;height:50px;color:#888;"></textarea>
		</div>
		
		<div class="validation">	
			<label for="salutation"><?php echo $this->__("Verification:");?></label>
			<span class="required">*</span><br />		
			<img src="<?php echo $this->getUrl("contacter/index/validation");?>?width=80&amp;height=23">
			<input type="text" name="validation" value="" class="input-text required-entry" style="width:50px;">	<br />			
			<span class="tips"><?php echo $this->__('Type the characters you see in the picture.');?></span>
		</div>
		
		<span>	
			<button class="button js_corner_4" type="submit"><span><?php echo $this->__("Submit Feedback");?></span></button>
		</span>
</div>




</form>
<script type="text/javascript">
//<![CDATA[
var dataForm = new VarienForm('sidebar_contacter', true);
//]]> 
</script>